Chris Sampson’s journal round-up for 19th November 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.

Valuation of health states considered to be worse than death—an analysis of composite time trade-off data from 5 EQ-5D-5L valuation studies. Value in Health Published 12th November 2018

I have a problem with the idea of health states being ‘worse than dead’, and I’ve banged on about it on this blog. Happily, this new article provides an opportunity for me to continue my campaign. Health state valuation methods estimate how much a person prefers being in a more healthy state. Positive values are easy to understand; 1.0 is twice as good as 0.5. But how about the negative values? Is -1.0 twice as bad as -0.5? How much worse than being dead is that? The purpose of this study is to evaluate whether or not negative EQ-5D-5L values meaningfully discriminate between different health states.

The study uses data from EQ-5D-5L valuation studies conducted in Singapore, the Netherlands, China, Thailand, and Canada. Altogether, more than 5000 people provided valuations of 10 states each. As a simple measure of severity, the authors summed the number of steps from full health in all domains, giving a value from 0 (11111) to 20 (55555). We’d expect this measure of severity of states to correlate strongly with the mean utility values derived from the composite time trade-off (TTO) exercise.

Taking Singapore as an example, the mean of positive values (states better than dead) decreased from 0.89 to 0.21 with increasing severity, which is reassuring. The mean of negative values, on the other hand, ranged from -0.98 to -0.89. Negative values were clustered between -0.5 and -1.0. Results were similar across the other countries. In all except Thailand, observed negative values were indistinguishable from random noise. There was no decreasing trend in mean utility values as severity increased for states worse than dead. A linear mixed model with participant-specific intercepts and an ANOVA model confirmed the findings.

What this means is that we can’t say much about states worse than dead except that they are worse than dead. How much worse doesn’t relate to severity, which is worrying if we’re using these values in trade-offs against states better than dead. Mostly, the authors frame this lack of discriminative ability as a practical problem, rather than anything more fundamental. The discussion section provides some interesting speculation, but my favourite part of the paper is an analogy, which I’ll be quoting in future: “it might be worse to be lost at sea in deep waters than in a pond, but not in any way that truly matters”. Dead is dead is dead.

Determining value in health technology assessment: stay the course or tack away? PharmacoEconomics [PubMed] Published 9th November 2018

The cost-per-QALY approach to value in health care is no stranger to assault. The majority of criticisms are ill-founded special pleading, but, sometimes, reasonable tweaks and alternatives have been proposed. The aim of this paper was to bring together a supergroup of health economists to review and discuss these reasonable alternatives. Specifically, the questions they sought to address were: i) what should health technology assessment achieve, and ii) what should be the approach to value-based pricing?

The paper provides an unstructured overview of a selection of possible adjustments or alternatives to the cost-per-QALY method. We’re very briefly introduced to QALY weighting, efficiency frontiers, and multi-criteria decision analysis. The authors don’t tell us why we ought (or ought not) to adopt these alternatives. I was hoping that the paper would provide tentative answers to the normative questions posed, but it doesn’t do that. It doesn’t even outline the thought processes required to answer them.

The purpose of this paper seems to be to argue that alternative approaches aren’t sufficiently developed to replace the cost-per-QALY approach. But it’s hardly a strong defence. I’m a big fan of the cost-per-QALY as a necessary (if not sufficient) part of decision making in health care, and I agree with the authors that the alternatives are lacking in support. But the lack of conviction in this paper scares me. It’s tempting to make a comparison between the EU and the QALY.

How can we evaluate the cost-effectiveness of health system strengthening? A typology and illustrations. Social Science & Medicine [PubMed] Published 3rd November 2018

Health care is more than the sum of its parts. This is particularly evident in low- and middle-income countries that might lack strong health systems and which therefore can’t benefit from a new intervention in the way a strong system could. Thus, there is value in health system strengthening. But, as the authors of this paper point out, this value can be difficult to identify. The purpose of this study is to provide new methods to model the impact of health system strengthening in order to support investment decisions in this context.

The authors introduce standard cost-effectiveness analysis and economies of scope as relevant pieces of the puzzle. In essence, this paper is trying to marry the two. An intervention is more likely to be cost-effective if it helps to provide economies of scope, either by making use of an underused platform or providing a new platform that would improve the cost-effectiveness of other interventions. The authors provide a typology with three types of health system strengthening: i) investing in platform efficiency, ii) investing in platform capacity, and iii) investing in new platforms. Examples are provided for each. Simple mathematical approaches to evaluating these are described, using scaling factors and disaggregated cost and outcome constraints. Numerical demonstrations show how these approaches can reveal differences in cost-effectiveness that arise through changes in technical efficiency or the opportunity cost linked to health system strengthening.

This paper is written with international development investment decisions in mind, and in particular the challenge of investments that can mostly be characterised as health system strengthening. But it’s easy to see how many – perhaps all – health services are interdependent. If anything, the broader impact of new interventions on health systems should be considered as standard. The methods described in this paper provide a useful framework to tackle these issues, with food for thought for anybody engaged in cost-effectiveness analysis.


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

Estimating health opportunity costs in low-income and middle-income countries: a novel approach and evidence from cross-country data. BMJ Global Health. Published November 2017.

The relationship between health care expenditure and population health outcomes is a topic that comes up often on this blog. Understanding how population health changes in response to increases or decreases in the health system budget is a reasonable way to set a cost-effectiveness threshold. Purchasing things above this threshold will, on average, displace activity with greater benefits. But identifying this effect is hard. Commonly papers use some kind of instrumental variable method to try to get at the causal effect with aggregate, say country-level, data. These instruments, though, can be controversial. Years ago I tried to articulate why I thought using socio-economic variables as instruments was inappropriate. I also wrote a short paper a few years ago, which remains unpublished, that used international commodity price indexes as an instrument for health spending in Sub-Saharan Africa, where commodity exports are a big driver of national income. This was rejected from a journal because of the choice of instruments. Commodity prices may well influence other things in the country that can influence population health. And a similar critique could be made of this article here, which uses consumption:investment ratios and military expenditure in neighbouring countries as instruments for national health expenditure in low and middle income countries.

I remain unconvinced by these instruments. The paper doesn’t present validity checks on them, which is forgiveable given medical journal word limitations, but does mean it is hard to assess. In any case, consumption:investment ratios change in line with the general macroeconomy – in an economic downturn this should change (assuming savings = investment) as people switch from consumption to investment. There are a multitude of pathways through which this will affect health. Similarly, neighbouring military expenditure would act by displacing own-country health expenditure towards military expenditure. But for many regions of the world, there has been little conflict between neighbours in recent years. And at the very least there would be a lag on this effect. Indeed, in all the models of health expenditure and population health outcomes I’ve seen, barely a handful take into account dynamic effects.

Now, I don’t mean to let the perfect be the enemy of the good. I would never have suggested this paper should not be published as it is, at the very least, important for the discussion of health care expenditure and cost-effectiveness. But I don’t feel there is strong enough evidence to accept these as causal estimates. I would even be willing to go as far to say that any mechanism that affects health care expenditure is likely to affect population health by some other means, since health expenditure is typically decided in the context of the broader public sector budget. That’s without considering what happens with private expenditure on health.

Strategic Patient Discharge: The Case of Long-Term Care Hospitals. American Economic Review. [RePEcPublished November 2018.

An important contribution of health economics has been to undermine people’s trust that doctors act in their best interest. Perhaps that’s a little facetious, nevertheless there has been ample demonstration that health care providers will often act in their own self-interest. Often this is due to trying to maximise revenue by gaming reimbursement schemes, but also includes things like doctors acting differently near the end of their shift so they can go home on time. So when I describe a particular reimbursement scheme that Medicare in the US uses, I don’t think there’ll be any doubt about the results of this study of it.

In the US, long-term acute care hospitals (LTCHs) specialise in treating patients with chronic care needs who require extended inpatient stays. Medicare reimbursement typically works on a fixed rate for each of many diagnostic related groups (DRGs), but given the longer and more complex care needs in LTCHs, they get a higher tariff. To discourage admitting patients purely to get higher levels of reimbursement, the bulk of the payment only kicks in after a certain length of stay. Like I said – you can guess what happened.

This article shows 26% of patients are discharged in the three days after the length of stay threshold compared to just 7% in the three days prior. This pattern is most strongly observed in discharges to home, and is not present in patients who die. But this may still be just by chance that the threshold and these discharges coincide. Fortunately for the authors the thresholds differ between DRGs and even move around within a DRG over time in a way that appears unrelated to actual patient health. They therefore estimate a set of decision models for patient discharge to try to estimate the effect of different reimbursement policies.

Estimating misreporting in condom use and its determinants among sex workers: Evidence from the list randomisation method. Health Economics. Published November 2018.

Working on health and health care research, especially if you conduct surveys, means you often want to ask people about sensitive topics. These could include sex and sexuality, bodily function, mood, or other ailments. For example, I work a fair bit on sanitation, where frequently self-reported diarrhoea in under fives (reported by the mother that is) is the primary outcome. This could be poorly reported particularly if an intervention includes any kind of educational component that suggests it could be the mother’s fault for, say, not washing her hands, if the child gets diarrhoea. This article looks at condom use among female sex workers in Senegal, another potentially sensitive topic, since unprotected sex is seen as risky. To try and get at the true prevalence of condom use, the authors use a ‘list randomisation’ method. This randomises survey participants to two sets of questions: a set of non-sensitive statements, or the same set of statements with the sensitive question thrown in. All respondents have to do is report the number of the statements they agree with. This means it is generally not possible to distinguish the response to the sensitive question, but the difference in average number of statements reported between the two groups gives an unbiased estimator for the population proportion. Neat, huh? Ultimately the authors report an estimate of 80% of sex workers using condoms, which compares to the 97% who said they used a condom when asked directly.



Sam Watson’s journal round-up for 8th October 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.

A cost‐effectiveness threshold based on the marginal returns of cardiovascular hospital spending. Health Economics [PubMed] Published 1st October 2018

There are two types of cost-effectiveness threshold of interest to researchers. First, there’s the societal willingness-to-pay for a given gain in health or quality of life. This is what many regulatory bodies, such as NICE, use. Second, there is the actual return on medical spending achieved by the health service. Reimbursement of technologies with a lesser return for every pound or dollar would reduce the overall efficiency of the health service. Some refer to this as the opportunity cost, although in a technical sense I would disagree that it is the opportunity cost per se. Nevertheless, this latter definition has seen a growth in empirical work; with some data on health spending and outcomes, we can start to estimate this threshold.

This article looks at spending on cardiovascular disease (CVD) among elderly age groups by gender in the Netherlands and survival. Estimating the causal effect of spending is tricky with these data: spending may go up because survival is worsening, external factors like smoking may have a confounding role, and using five year age bands (as the authors do) over time can lead to bias as the average age in these bands is increasing as demographics shift. The authors do a pretty good job in specifying a Bayesian hierarchical model with enough flexibility to accommodate these potential issues. For example, linear time trends are allowed to vary by age-gender groups and  dynamic effects of spending are included. However, there’s no examination of whether the model is actually a good fit to the data, something which I’m growing to believe is an area where we, in health and health services research, need to improve.

Most interestingly (for me at least) the authors look at a range of priors based on previous studies and a meta-analysis of similar studies. The estimated elasticity using information from prior studies is more ‘optimistic’ about the effect of health spending than a ‘vague’ prior. This could be because CVD or the Netherlands differs in a particular way from other areas. I might argue that the modelling here is better than some previous efforts as well, which could explain the difference. Extrapolating using life tables the authors estimate a base case cost per QALY of €40,000.

Early illicit drug use and the age of onset of homelessness. Journal of the Royal Statistical Society: Series A Published 11th September 2018

How the consumption of different things, like food, drugs, or alcohol, affects life and health outcomes is a difficult question to answer empirically. Consider a recent widely-criticised study on alcohol published in The Lancet. Among a number of issues, despite including a huge amount of data, the paper was unable to address the problem that different kinds of people drink different amounts. The kind of person who is teetotal may be so for a number of reasons including alcoholism, interaction with medication, or other health issues. Similarly, studies on the effect of cannabis consumption have shown among other things an association with lower IQ and poorer mental health. But are those who consume cannabis already those with lower IQs or at higher risk of psychoses? This article considers the relationship between cannabis and homelessness. While homelessness may lead to an increase in drug use, drug use may also be a cause of homelessness.

The paper is a neat application of bivariate hazard models. We recently looked at shared parameter models on the blog, which factorise the joint distribution of two variables into their marginal distribution by assuming their relationship is due to some unobserved variable. The bivariate hazard models work here in a similar way: the bivariate model is specified as the product of the marginal densities and the individual unobserved heterogeneity. This specification allows (i) people to have different unobserved risks for both homelessness and cannabis use and (ii) cannabis to have a causal effect on homelessness and vice versa.

Despite the careful set-up though, I’m not wholly convinced of the face validity of the results. The authors claim that daily cannabis use among men has a large effect on becoming homeless – as large an effect as having separated parents – which seems implausible to me. Cannabis use can cause psychological dependency but I can’t see people choosing it over having a home as they might with something like heroin. The authors also claim that homelessness doesn’t really have an effect on cannabis use among men because the estimated effect is “relatively small” (it is the same order of magnitude as the reverse causal effect) and only “marginally significant”. Interpreting these results in the context of cannabis use would then be difficult, though. The paper provides much additional material of interest. However, the conclusion that regular cannabis use, all else being equal, has a “strong effect” on male homelessness, seems both difficult to conceptualise and not in keeping with the messiness of the data and complexity of the empirical question.

How could health care be anything other than high quality? The Lancet: Global Health [PubMed] Published 5th September 2018

Tedros Adhanom Ghebreyesus, or Dr Tedros as he’s better known, is the head of the WHO. This editorial was penned in response to the recent Lancet Commission on Health Care Quality and related studies (see this round-up). However, I was critical of these studies for a number of reasons, in particular, the conflation of ‘quality’ as we normally understand it and everything else that may impact on how a health system performs. This includes resourcing, which is obviously low in poor countries, availability of labour and medical supplies, and demand side choices about health care access. The empirical evidence was fairly weak; even in countries like in the UK in which we’re swimming in data we struggle to quantify quality. Data are also often averaged at the national level, masking huge underlying variation within-country. This editorial is, therefore, a bit of an empty platitude: of course we should strive to improve ‘quality’ – its goodness is definitional. But without a solid understanding of how to do this or even what we mean when we say ‘quality’ in this context, we’re not really saying anything at all. Proposing that we need a ‘revolution’ without any real concrete proposals is fairly meaningless and ignores the massive strides that have been made in recent years. Delivering high-quality, timely, effective, equitable, and integrated health care in the poorest settings means more resources. Tinkering with what little services already exist for those most in need is not going to produce a revolutionary change. But this strays into political territory, which UN organisations often flounder in.

Editorial: Statistical flaws in the teaching excellence and student outcomes framework in UK higher education. Journal of the Royal Statistical Society: Series A Published 21st September 2018

As a final note for our academic audience, we give you a statement on the Teaching Excellence Framework (TEF). For our non-UK audience, the TEF is a new system being introduced by the government, which seeks to introduce more of a ‘market’ in higher education by trying to quantify teaching quality and then allowing the best-performing universities to charge more. No-one would disagree with the sentiment that improving higher education standards is better for students and teachers alike, but the TEF is fundamentally statistically flawed, as discussed in this editorial in the JRSS.

Some key points of contention are: (i) TEF doesn’t actually assess any teaching, such as through observation; (ii) there is no consideration of uncertainty about scores and rankings; (iii) “The benchmarking process appears to be a kind of poor person’s propensity analysis” – copied verbatim as I couldn’t have phrased it any better; (iv) there has been no consideration of gaming the metrics; and (v) the proposed models do not reflect the actual aims of TEF and are likely to be biased. Economists will also likely have strong views on how the TEF incentives will affect institutional behaviour. But, as Michael Gove, the former justice and education secretary said, Britons have had enough of experts.