Sam Watson’s journal round-up for 25th February 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.

Democracy does cause growth. Journal of Political Economy [RePEc] Published January 2019

Citizens of a country with a democratic system of government are able to affect change in its governors and influence policy. This threat of voting out the poorly performing from power provides an incentive for the government to legislate in a way that benefits the population. However, democracy is certainly no guarantee of good governance, economic growth, or population health as many events in the last ten years will testify. Similarly, non-democracies can also enact policy that benefits the people. A benevolent dictator is not faced with the same need to satisfy voters and can enact politically challenging but beneficial policies. People often point to China as a key example of this. So there remains the question as to whether democracy per se has any tangible economic or health benefits.

In a past discussion of an article on democratic reform and child health, I concluded that “Democratic reform is neither a sufficient nor necessary condition for improvements in child mortality.” Nevertheless democracy may still be beneficial, on average, given the in-built safeguards against poor leaders. This paper, which has been doing the rounds for years as a working paper, is another examination of the question of the impact of becoming democratic. Principally the article is focused on economic growth, but health and education outcomes feature (very) briefly. The concern I have with the article mentioned at the beginning of this paragraph and with this newly published article are that they do not consider in great detail why democratisation occurred. As much political science work points out, democratic reform can be demanded in poor economic conditions due to poor governance. For these endogenous changes economic growth causes democracy. Whereas in other countries democracy could come about in a more exogenous manner. Lumping them all in together may be misleading.

While the authors of this paper provide pages after pages of different regression specifications, including auto-regressive models and instrumental variables models, I remain unconvinced. For example, the instrument relies on ‘waves’ of transitions: a country is more likely to shift politically if its regional neighbours do, like the Arab Spring. But neither economic nor political conditions in a given country are independent of its neighbours. In somewhat of a rebuttal, Ruiz Pozuelo and other authors conducted a survey to try to identify and separate out those countries which transitioned to democracy endogenously and exogenously (from economic conditions). Their work suggests that the countries that transitioned exogenously did not experience growth benefits. Taken together this shows the importance of theory to guide empirical work, and not the other way round.

Effect of Novartis Access on availability and price of non-communicable disease medicines in Kenya: a cluster-randomised controlled trial. Lancet: Global Health Published February 2019

Access to medicines is one of the key barriers to achieving universal health care. The cost-effectiveness threshold for many low income countries rules out many potentially beneficial medicines. This is in part driven though by the high prices charged by pharmaceutical countries to purchase medicine, which often do not discriminate between purchasers with high and low abilities to pay. Novartis launched a scheme – Novartis Access – to provide access to medicines to low and middle income countries at a price of US$1 per treatment per month. This article presents a cluster randomised trial of this scheme in eight counties of Kenya.

The trial provided access to four treatment counties and used four counties as controls. Individuals selected at random within the counties with non-communicable diseases and pharmacies were the principal units within the counties at which outcomes were analysed. Given the small number of clusters, a covariate-constrained randomisation procedure was used, which generates randomisation that ensures a decent balance of covariates between arms. However, the analysis does not control for the covariates used in the constrained randomisation, which can lead to lower power and incorrect type one error rates. This problem is emphasized by the use of statistical significance to decide on what was and was not affected by the Novartis Access program. While practically all the drugs investigated show an improved availability, only the two with p<0.05 are reported to have improved. Given the very small sample of clusters, this is a tricky distinction to make! Significance aside, the programme appears to have had some success in improving access to diabetes and asthma medication, but not quite as much as hoped. Introductory microeconomics though would show how savings are not all passed on to the consumer.

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Harold Hastings’s journal round-up for 16th July 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.

Legal origins and female HIV. American Economic Review [RePEc] Published 13th June 2018

I made this somewhat unusual choice because the author Siwan Anderson draws an important connection between the economic and legal status of women across sub-Saharan Africa and the incidence of HIV. As summarized in the American Economic Review feature Empowering women, improving health, “Over half of all people living with HIV are women. Of all HIV-positive women, 80 percent live in Sub-Saharan Africa.” Anderson hypothesizes that regional differences in female property rights (lower in common law eastern and southern Africa than in civil law central Africa) may explain significantly higher HIV incidence in eastern and southern African women, especially relative to eastern and southern African men. Health economists have long studied how economic status affects access to health care; Anderson presents an important and interesting complementary argument for how economic (and legal) status affects health. In particular, improved legal status and access to legal aid may be a key step in improving women’s health.

Addressing generic-drug market failures — the case for establishing a nonprofit manufacturer. The New England Journal of Medicine [PubMed] Published 17th May 2018

We have recently seen shortages in many generic drugs, including generic injectables used in emergency, trauma and other hospital medicine. In many cases, there is only a single supplier, who can dramatically increase prices. One might expect others to enter the market in this case. However, frequently significant fixed start-up costs pose a barrier to entry and the single supplier, who has already made and in many cases paid for the start-up investment, can drastically reduce prices to make it difficult for the competition to cover these costs. Thus there is little incentive to enter a potentially low-profit market. The authors propose establishing a nonprofit manufacturer, essentially a pharmaceutical counterpart to a variety of national and nonprofit health systems, as a novel and a potentially successful way to address this issue.

An incomplete prescription: President Trump’s plan to address high drug prices. JAMA [PubMed] Published 19th June 2018

The prices of many drugs are significantly higher in the United States than in much of the rest of the developed world. President Trump proposes some market actions such as granting Medicare negotiating power; but the authors find these insufficient, making two interesting additional proposals. First, since much pharmaceutical development derives from NIH funded research (including chimeric antigen receptor T-cell immunotherapies which may cost $400,000 US per dose), the authors argue that the NIH and academic institutions could require US prices based upon independent valuations or not to exceed those in other industrialized countries. The authors also suggest authorizing imports where there is adequate regulation as a further mechanism for controlling drug prices; in my opinion a natural free-trade position. The pricing of pharmaceuticals remains complex and perhaps new economic models are needed to address the risk and cost of pharmaceutical development. Kenneth Arrow’s critiques of the limitations of economics to address health issues might provide interesting insights.

Cost-related insulin underuse is common and associated with poor glycemic control. Diabetes Published July 2018

I would like to conclude by citing a recent abstract providing a human side to the growing cost of pharmaceuticals. Darby Herkert (a Yale undergraduate) reported that a quarter of almost 200 patient responses to a survey of patients at a New Haven, CT, USA diabetes center reported cost-related insulin underuse. Underuse was prevalent among patients with lower income levels, patients without full-time employment, and patients without employer-provided insurance, Medicare or Medicaid. Patients reporting underuse had three times the incidence of of HbA1c >9%. These results cite the human costs of high insulin prices in the US. A Medscape review cites the high cost of typically prescribed insulin analogs, and quotes the lead author calling these prices irrational and describing patients living near the Mexican border crossing the border to buy their insulin.

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Chris Sampson’s journal round-up for 23rd April 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.

What should we know about the person behind a TTO? The European Journal of Health Economics [PubMed] Published 18th April 2018

The time trade-off (TTO) is a staple of health state valuation. Ask someone to value a health state with respect to time and – hey presto! – you have QALYs. This editorial suggests that completing a TTO can be a difficult task for respondents and that, more importantly, individuals’ characteristics may determine the way that they respond and therefore the nature of the results. One of the most commonly demonstrated differences, in this respect, is the fact that valuations of people’s own health states tend to be higher than health states valued hypothetically. But this paper focuses on indirect (hypothetical) valuations. The authors highlight mixed evidence for the influence of age, gender, marital status, having children, education, income, expectations about the future, and of one’s own health state. But why should we try and find out more about respondents when conducting TTOs? The authors offer 3 reasons: i) to inform sampling, ii) to inform the design and standardisation of TTO exercises, and iii) to inform the analysis. I agree – we need to better understand these sources of heterogeneity. Not to over-engineer responses, but to aid our interpretation, even if we want societally-representative valuations that include all of these variations in response behaviour. TTO valuation studies should collect data relating to the individual respondents. Unfortunately, what those data should be aren’t listed in this study, so the research question in the title isn’t really answered. But maybe that’s something the authors have in hand.

Computer modeling of diabetes and its transparency: a report on the eighth Mount Hood Challenge. Value in Health Published 9th April 2018

The Mount Hood Challenge is a get-together for people working on the (economic) modelling of diabetes. The subject of the 2016 meeting was transparency, with two specific goals: i) to evaluate the transparency of two published studies, and ii) to develop a diabetes-specific checklist for transparent reporting of modelling studies. Participants were tasked (in advance of the meeting) with replicating the two published studies and using the replicated models to evaluate some pre-specified scenarios. Both of the studies had some serious shortcomings in the reporting of the necessary data for replication, including the baseline characteristics of the population. Five modelling groups replicated the first model and seven groups replicated the second model. Naturally, the different groups made different assumptions about what should be used in place of missing data. For the first paper, none of the models provided results that matched the original. Not even close. And the differences between the results of the replications – in terms of costs incurred and complications avoided – were huge. The performance was a bit better on the second paper, but hardly worth celebrating. In general, the findings were fear-confirming. Informed by these findings, the Diabetes Modeling Input Checklist was created, designed to complement existing checklists with more general applications. It includes specific data requirements for the reporting of modelling studies, relating to the simulation cohort, treatments, costs, utilities, and model characteristics. If you’re doing some modelling in diabetes, you should have this paper to hand.

Setting dead at zero: applying scale properties to the QALY model. Medical Decision Making [PubMed] Published 9th April 2018

In health state valuation, whether or not a state is considered ‘worse than dead’ is heavily dependent on methodological choices. This paper reviews the literature to answer two questions: i) what are the reasons for anchoring at dead=0, and ii) how does the position of ‘dead’ on the utility-scale impact on decision making? The authors took a standard systematic approach to identify literature from databases, with 7 papers included. Then the authors discuss scale properties and the idea that there are interval scales (such as temperature) and ratio scales (such as distance). The difference between these is the meaningfulness of the reference point (or origin). This means that you can talk about distance doubling, but you can’t talk about temperature doubling, because 0 metres is not arbitrary, whereas 0 degrees Celsius is. The paper summarises some of the arguments put forward for using dead=0. They aren’t compelling. The authors argue that the duration part of the QALY (i.e. time) needs to have ratio properties for the QALY model to function. Time obviously holds this property and it’s clear that duration can be anchored at zero. The authors then demonstrate that, for the QALY model to work, the health-utility scale must also exhibit ratio scale properties. The basis for this is the assumption that zero duration nullifies health states and that ‘dead’ nullifies duration. But the paper doesn’t challenge the conceptual basis for using dead in health state valuation exercises. Rather, it considers the mathematical properties that must hold to allow for dead=0, and asserts them. The authors’ conclusion that dead “needs to have the value of 0 in a QALY model” is correct, but only within the existing restrictions and assumptions underlying current practice. Nevertheless, this is a very useful study for understanding the challenge of anchoring and explicating the assumptions underlying the QALY model.

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