Alastair Canaway’s journal round-up for 31st October 2016

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.

Ethical hurdles in the prioritization of oncology care. Applied Health Economics and Health Policy [PubMedPublished 21st October 2016

Recently between health economists, there has been significant scrutiny and disquiet directed towards the Cancer Drugs Fund with Professor Karl Claxton describing it as “an appalling, unfair use of NHS resources”. With the latest reorganization of the Cancer Drugs Fund in mind, this article examining the ethical issues surrounding prioritisation of cancer care was of particular interest. As all health economists will tell you, there is an opportunity cost with any allocation of scarce resources. Likewise, with prioritisation of specific disease groups, there may be equity issues with specific patients’ lives essentially being valued more greatly than those suffering other conditions. This article conducts a systematic review of the oncology literature to examine the ethical issues surrounding inequity in healthcare. The review found that public and political attention often focuses on ‘availability’ of pharmacological treatment in addition to factors that lead to good outcomes. The public and political focus on availability can have perverse consequences as highlighted by the Cancer Drugs Fund: resources are diverted towards availability and away from other more cost-effective areas, and in turn this may have had a detrimental effect on care for non-cancer patients. Additionally, by approving high cost, less cost-effective agents, strain will be placed upon health budgets and causing problems for existing cost-effectiveness thresholds. If prioritisation for cancer drugs is to be pursued then the authors suggest that the question of how to fund new therapies equitably will need to be addressed. Although the above issues will not be new to most, the paper is still worth reading as it: i) gives an overview of the different prioritisation frameworks used across Europe, ii) provides several suggestions for how, if prioritization is to be pursued, it can be done in a fairer manner rather than simply overriding typical HTA decision processes, iii) considers the potential legal consequences of prioritisation and iv) the impact of prioritisation on the sustainability of healthcare funding.

Doctor-patient differences in risk and time preferences: a field experiment. Journal of Health Economics Published 19th October 2016

The patient-doctor agency interaction, and associated issues due to asymmetrical information is something that was discussed often during my health economics MSc, but rarely during my day to day work. Despite being very familiar with supplier induced demand, differences in risk and time preferences in the patient-doctor dyad wasn’t something I’d considered in recent times. Upon reading, immediately, it is clear that if risk and time preferences do differ, then what is seen as the optimal treatment for the patient may be very different to that of the doctor. This may lead to poorer adherence to treatments and worse outcomes. This paper sought to investigate whether patients and their doctors had similar time and risk preferences using a framed field experiment with 300 patients and 67 doctors in Athens, Greece in a natural clinical setting. The authors claim to be the first to attempt this, and have three main findings: i) there were significant time preference differences between the patients and doctors – doctors discounted future health gains and financial outcomes less heavily than patients; ii) there were no significant differences in risk preferences for health with both doctors and patients being mildly risk averse; iii) there were however risk preference differences for financial impacts with doctors being more risk averse than patients. The implication of this paper is that there is potential for improvements in doctor-patient communication for treatments, and as agents for patients, doctors should attempts to gauge their patient’s preferences and attitudes before recommending treatment. For those who heavily discount the future it may be preferable to provide care that increases the short term benefits.

Hospital productivity growth in the English NHS 2008/09 to 2013/14 [PDF]. Centre for Health Economics Research Paper [RePEcPublished 21st October 2016

Although this is technically a ‘journal round-up’, this week I’ve chosen to include the latest CHE report as I think it is something which may be of wider interest to the AHEBlog community. Given limited resources, there is an unerring call for both productivity and efficiency gains within the NHS. The CHE report examines the extent to which NHS hospitals have improved productivity: have they made better use of their resources by increasing the number of patients they treat and the services they deliver for the same or fewer inputs. To assess productivity, the report uses established methods: Total Factor Productivity (TFP) which is the ratio of all outputs to all inputs. Growth in TFP is seen as being key to improving patient care with limited resources. The primary report finding was that TFP growth at the trust level exhibits ‘extraordinary volatility’. For example one year there maybe TFP growth followed by negative growth the next year, and then positive growth. The authors assert that much of the TFP growth measured is in fact implausible, and much of the changes are driven largely by nominal effects alongside some real changes. These nominal effects may be data entry errors or changes in accounting practices and data recording processes which results in changes to the timing of the recording of outputs and inputs. This is an important finding for research assessing productivity growth within the NHS. The TFP approach is an established methodology, yet as this research demonstrates, such methods do not provide credible measures of productivity at the hospital level. If hospital level productivity growth is to be measured credibly, then a new methodology will be required.

Credits

#HEJC for 03/06/2013

This month’s meeting will take place Monday 3rd June, at 5pm London time. That’ll be midday in Boston and 6pm in Geneva. Join the Facebook event here. We’ll also hold an antipodal meeting 12 hours later on Tuesday 4th June, at 5am London time. That’ll be midday in Beijing and 6pm on Monday in Honolulu. Join the Facebook event here. For more information about the Health Economics Twitter Journal Club and how to take part, click here.

The paper for discussion this month is a working paper published by the National Bureau of Economic Research. The authors are Janet Currie and W. Bentley MacLeodThe title of the paper is:

“Diagnosis and unnecessary procedure use: evidence from C-section”

Following the meeting, a transcript of the discussion can be downloaded here.

Links to the article

Direct: http://www.nber.org/papers/w18977

RePEc: http://ideas.repec.org/p/nbr/nberwo/18977.html

Other: tbc

Summary of the paper

In this paper the authors develop a model of diagnostic skill as an element of provider quality that is separate from a doctor’s skill in performing procedures. The model shows that higher surgical skill leads to higher use of surgical procedures across all patients, while better diagnostic skill results in fewer procedures for the low risk and more procedures for the high risk. When doctors face a dichotomous choice between an intensive and a non-intensive procedure they have a threshold level of patient condition; above which patients receive the intensive procedure and below which they receive the non-intensive procedure. The doctor’s threshold level is dependent on their surgical skill and the pecuniary benefit associated with carrying out the procedure. Greater diagnostic skill improves the precision of the doctor’s estimate of a patient’s condition and therefore improves the matching between patients and procedures; leading to better health outcomes. Taking the model to data on C-sections, the most common surgical procedure performed in the U.S., the authors show that improving diagnostic skills from the 25th to the 75th percentile of the observed distribution would reduce C-section rates by 11.7% among the low risk, and increase them by 4.6% among the high risk. Since there are many more low risk than high risk women, improving diagnosis would reduce overall C-section rates by about 5% of total births. Moreover, such an improvement in diagnostic skill would improve health outcomes for both high risk and low risk women, while improvements in surgical skill have the greatest impact on high risk women. The results are consistent with the hypothesis that efforts to improve diagnosis through methods such as checklists, computer assisted diagnosis, and collaborative decision making may improve patient outcomes.

Discussion points

  • Are there other aspects of physician skill that could be estimated in this way?
  • Is the characterisation of a doctor’s payoffs accurate?
  • To what other procedures could the model be applied?
  • To what extent could this model inform non-dichotomous physician decisions?
  • What are the key policy implications of these findings?

Missed the meeting? Add your thoughts on the paper in the comments below.