Brendan Collins’s journal round-up for 22nd July 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.

Making hard choices in local public health spending with a cost-benefit analysis approach. Frontiers in Public Health Published 29th June 2019

In this round-up I have chosen three papers which look broadly at public health economics.

While NHS healthcare funding has been relatively preserved in the UK (in financial terms at least, though not keeping up with demographic change), funding for local government public health departments has been cut. These departments commission early years services, smoking cessation, drug and alcohol treatment, sexual health, and lots of other services. A recent working paper suggests that marginal changes in Public Health funding produce a more favourable ICER than changes in NHS funding.

This is a neat paper looking at the cost-benefit for a subset of £14 million investment in public health programmes in Dorset, a county on the south coast of England, whose population is slightly older and more affluent than the England average. I try to go to Dorset every year, it has beautiful beaches with traditional Punch and Judy shows, and nice old towns where you can get out on a mackerel fishing trip.

This paper looks at the potential financial savings for each public health programme across different sectors of the economy. One of the big issues with public health as opposed to clinical interventions is the cross sector flow problem – you spend money on drug and alcohol treatment, but the majority of benefits are through prevented crime; or you prevent teenage pregnancy, and a lot of the benefits are to the welfare system (because women delay pregnancy until they are more likely to be in a stable relationship and working). This makes it hard when local councillors might say, ‘what’s in it for us?’

Figure 2 in this paper shows the cross sector flow issue clearly – the spend comes from local authority public health, but 94% of the financial benefits are in the NHS.

I think this study has a good blueprint that other local authorities could follow. The study applies an optimism bias reduction, so it is not just assuming that programmes will be as effective as the research evidence suggests. This is important as there may be a big drop off in effectiveness when something is implemented locally. Of course, sometimes local implementation might be more effective. But it would be nice to see this kind of study carried out with more real-world data. Although the optimism bias reduction makes it less likely to overestimate the cost-benefit, it doesn’t necessarily make the estimate any more precise. National outcomes data collection for public health programmes is weak or absent; better data collection might mean more evidence that prevention interventions provide value for money.

Impact of sugar‐sweetened beverage taxes on purchases and dietary intake: systematic review and meta‐analysis. Obesity Reviews [PubMed] Published 19th June 2019

A lot of health economics focuses on healthcare interventions. But, upstream, structural policy interventions have the capacity to be a lot more cost effective in preventing ill health. Sugary drinks (sugar sweetened beverages – SSBs) are a source of excess empty calories and increase the risk of cardiovascular disease, diabetes and early death. One of the first pieces of work I did as a grown-up academic was looking at a sugary drinks tax, which resulted in me getting up early one day and seeing this. At the time I thought it had roughly zero chance of being implemented. But the sugary drinks industry levy (SDIL) was implemented in the UK in April last year, and had a huge effect in terms of motivating the industry to reformulate below the thresholds of 5g and 8g of sugar per 100ml. Milk-based drinks like Frijj and Yazoo are exempt and still often have nearly 10g sugar per 100ml so there has been talk of extending the tax to these drinks. But Boris Johnson, the likely next UK Prime Minister, has come out against these ‘nanny state’ ‘sin taxes’ and said he will review them, seemingly despite there being a large scale evaluation of the SDIL, and a growing evidence base. There is a good twitter thread on this by Adam Briggs here.

Policies like the SDIL rely on price elasticity of demand (PED). But this PED varies depending, for instance, on how addictive something is and the availability of substitutes. For tobacco, because it is addictive, a 10% price increase might only produce a 5% reduction in demand.

This systematic review and meta-analysis looked at data from 17 studies in 6 jurisdictions and found that, on average, sugar consumption is unit elastic – a 10% price increase produces a 10% reduction in purchases. However, there was considerable variation between studies. The authors designed a bespoke risk of bias tool for this, as the traditional tools used for health interventions did not include all of the potential biases for an SSB tax evaluation; this checklist may be useful for future analyses of similar policies.

If the SSB duty produced a unit elastic response in the UK, it means that people aren’t spending more on SSBs, they are merely buying less of something that they don’t need and which damages their health. And maybe a few people, over many years, consume a bit less sugar, don’t get type 2 diabetes, don’t have to give up work, and are actually better off and can provide for their families for a bit longer. Of course, in the UK the picture is complex because of the different tiers of the duty, but reformulation has meant that people are consuming less sugar even if they don’t reduce their sugary drink consumption. Also, the revenue from the SDIL is spent on healthier schools, so it could be argued that the policy is a win-win.

The cost of not breastfeeding: global results from a new tool. Health Policy & Planning [PubMed] Published 24th June 2019

This study looks at the potential worldwide cost savings if breastfeeding rates were improved. Breastfeeding prevents cases of diarrhoea, obesity, maternal cancer, and other diseases and adverse outcomes. Low breastfeeding rates are a big problem in developing countries where formula costs a huge proportion of income (nearly 20% of average household income in India and Pakistan according to this paper) and water supplies may be contaminated. This study includes healthcare costs, and economic losses from early deaths and reduced IQ through sub-optimal breastfeeding, which total $341 billion per year worldwide.

The authors have said there is also going to be an online, and Excel-based, results tool.

I love reading such ambitious studies that cover the whole world. Producing worldwide estimates for costs is a difficult exercise and can have a danger of losing meaning. For instance, in developing countries, medical costs may be very low if health coverage is very sparse. If a country doesn’t spend anything on healthcare and you measure public health interventions in healthcare cost savings, then it looks like these public health interventions are not worth doing. That is why it is sometimes better to focus on DALYs (and potentially put a financial value on them, although this can be controversial) rather than financial costs. The study found the biggest absolute costs of not breastfeeding were in North America ($115bn), while biggest costs as a proportion of gross national income (GNI) were for sub-Saharan Africa, where not breastfeeding cost 2.6% of GNI.

It looks like two out of the three authors are men. Is there a problem with men being pro-breastfeeding? Why should a man tell women what to do with their bodies? Women shouldn’t feel stigmatised about their infant feeding choices. But for me it is not about telling women what to do. It is making sure the structures and social norms are there to support breastfeeding and that formula companies are regulated in how they market themselves and their products. Maybe men not caring enough about breastfeeding is what has got us to where we are now. 

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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.

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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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