Chris Sampson’s journal round-up for 27th January 2020

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 general framework for classifying costing methods for economic evaluation of health care. The European Journal of Health Economics [PubMed] Published 20th January 2020

When it comes to health state valuation and quality of life, I’m always very concerned about the use of precise terminology, and it bugs me when people get things wrong. But when it comes to costing methods, I’m pretty shoddy. So I’m pleased to see this very useful paper, which should help us all to gain some clarity in our reporting of costing studies.

The authors start out by clearly distinguishing between micro-costing and gross-costing in the identification of costs and between top-down and bottom-up valuation of these costs. I’m ashamed to say that I had never properly grasped the four distinct approaches that can be adopted based on these classifications, but the authors make it quite clear. Micro-costing means detailed identification of cost components, while gross-costing considers resource use in aggregate. Top-down methods use expenditure data collected at the organisational level, while bottom-up approaches use patient-level data.

A key problem is that our language – as health economists – is in several respects contradictory to the language used by management accountants. It’s the accountants who are usually preparing the cost information that we might use in analyses, and these data are not normally prepared for the types of analysis that we wish to conduct, so there is a lot that can go awry. Perhaps most important is that financial accounting is not concerned with opportunity costs. The authors provide a kind of glossary of terms that can support translation between the two contexts, as well as a set of examples of the ways in which the two contexts differ. They also point out the importance of different accounting practices in different countries and the ways in which these might necessitate adjustment in costing methods for economic evaluation.

The study includes a narrative review of costing studies in order to demonstrate the sorts of errors in terminology that can arise and the lack of clarity that results. The studies included in the review provide examples of the different approaches to costing, though no study is identified as ‘bottom-up gross-costing’. One of the most useful contributions of the paper is to provide two methodological checklists, one for top-down and one for bottom-up costing studies. If you’re performing, reviewing, or in any way making use of costing studies, this will be a handy reference.

Health state values of deaf British Sign Language (BSL) users in the UK: an application of the BSL version of the EQ-5D-5L. Applied Health Economics and Health Policy [PubMed] Published 16th January 2020

The BSL translation of the EQ-5D is like no other. It is to be used – almost exclusively – by people who have a specific functional health impairment. For me, this raises questions about whether or not we can actually consider it simply a translation of the EQ-5D and compare values with other translations in the way we would any other language. This study uses data collected during the initial development and validation of the EQ-5D-5L BSL translation. The authors compared health state utility values from Deaf people (BSL users) with a general population sample from the Health Survey for England.

As we might expect, the Deaf sample reported a lower mean utility score (0.78) than the general population (0.84). Several other health measures were used in the BSL study. A staggering 43% of the Deaf participants had depression and a lot of the analysis in the paper is directed towards comparing the groups with and without psychological distress. The authors conduct some simple regression analyses to explore what might be the determinants of health state utility values in the Deaf population, with long-standing physical illness having the biggest impact.

I had hoped that the study might be able to tell us a bit more about the usefulness of the BSL version of the EQ-5D-5L, because the EQ-5D has previously been shown to be insensitive to hearing problems. The small sample (<100) can’t tell us a great deal on its own, so it’s a shame that there isn’t some attempt at matching with individuals from the Health Survey for England for the sake of comparison. Using the crosswalk from the EQ-5D-3L to obtain 5L values is also a problem, as it limits the responsiveness of index values. Nevertheless, it’s good to see data relating to this under-represented population.

A welfare-theoretic model consistent with the practice of cost-effectiveness analysis and its implications. Journal of Health Economics [PubMed] Published 11th January 2020

There are plenty of good reasons to deviate from a traditional welfarist approach to cost-benefit analysis in the context of health care, as health economists have debated for decades. But it is nevertheless important to understand the ways in which cost-effectiveness analysis, as we conduct it, deviates from welfarism, and to aim for some kind of consistency in our handling of different issues. This paper attempts to draw together disparate subjects of discussion on the theoretical basis for aspects of cost-effectiveness analysis. The author focuses on issues relating to the inclusion of future (unrelated) costs, to discounting, and to consistency with welfarism, in the conduct of cost-per-QALY analyses. The implications are given consideration with respect to adopting a societal perspective, recognising multiple budget holders, and accounting for distributional impacts.

All of this is based on the description of an intertemporal utility model and a model of medical care investment. The model hinges especially on how we understand consumption to be affected by our ambition to maximise QALYs. For instance, the author argues that, once we consider time preferences in an overall utility function, we don’t need to worry about differential discounting in health and consumption. The various implications of the model are compared to the recommendations of the Second Panel on Cost-Effectiveness in Health and Medicine. In general, the model supports the recommendations of the Panel, where others have been critical. As such, it sets out some of the theoretical basis for those recommendations. It also implies other recommendations, not considered by the Panel. For example, the optimal cost-effectiveness threshold is likely to be higher than GDP per capita.

It’s difficult to judge the validity of the framework from a first read. The paper is dense with theoretical exposition. My first instinct is ‘so what’. One of the great things about the practice of cost-effectiveness analysis in health care is that it isn’t constrained by restrictive theoretical frameworks, and so the very idea of a kind of unified theoretical framework is a bit worrying to me. But my second thought is that this is a valuable paper, as it attempts to gather up several loose threads. Whether or not these can be gathered up within a welfarist framework is debatable, but the exercise is revealing. I suspect this paper will help to trigger further inquiry, which can only be a good thing.

Registered reports: time to radically rethink peer review in health economics. PharmacoEconomics – Open [PubMed] Published 23rd January 2020

As a discipline, health economics isn’t great when it comes to publication practices. We excel in neither the open access culture of medical sciences nor the discussion paper culture of economics proper. In this article, the authors express concern about publication bias, and the fact that health economics journals – and health economists in general – aren’t doing much to combat it. In fairness to the discipline, there isn’t really any evidence that publication bias abounds. But that isn’t really the point. We should be able to prove and ensure that it doesn’t if we want our research to been seen as credible.

One (partial) solution to publication bias is the adoption – by journals – of registered reports. Under such a system, researchers would submit study protocols to journals for peer review. If the journal were satisfied with the methods then they could guarantee to publish the study once the results are in, regardless of how sexy the results may or may not be. The authors of this paper identify the prevalence of studies in major health economics journals that could benefit from registered reports. These would be prospectively designed experimental or quasi-experimental studies. It seems that there are plenty.

I’ve used this blog in the past to propose more transparent research practices and to complain about publication practices in health economics generally, while others have complained about the use of p-values in our discipline. The adoption of registered reports is one tactic that could bring improvements and I hope it will be given proper consideration by those in a position to enact change.

Credits

Meeting round-up: 18th European Health Economics Workshop (EHEW)

I attended the European Health Economics Workshop (EHEW) in Oslo. The workshop has been running for almost 20 years and it shows. Most participants have attended many editions of EHEW, which has and continues to shape the field of health economics theory. This is “the theory workshop”. The atmosphere is one of great friendship and constructive feedback, based on long-term collaborations that set the tone of the workshop. I am definitely not a theorist but found a very welcoming group of people, interested in fostering collaboration between theory, experiments, and empirical work.

EHEW is also a perfect example of the law of small numbers. The smaller the workshop, the more useful the feedback. The smaller the workshop, the larger the potential for fruitful research co-authorship.

Over two days, we went through 15 papers, building up to a total of not more than 30 participants, all of whom had an active role. The author presents in 25 minutes, followed by 10 minutes from the discussant and floor debate, a format that has become the golden rule.

We started off the proper way, with a wine reception at our headquarters hotel in downtown Oslo. I have to say, the organizers – Tor Iversen, Oddvar Kaarboe and Jan Erik Askildsen – did a terrific job. We all know what people remember from a workshop or conference: food and venue. It will be hard to beat EHEW Oslo (although we are possibly headed to Paris next year). We spent Friday and Saturday in an old stable, transformed into a delightful meeting room (see below). The catering was also on point, but what really stood out were the dinners. I think we can all agree that the dinner on Friday night was the best conference meal of all time; a 4-course dinner with paired wine at Restaurant Eik (I leave this here in case you ever go to Oslo – trust me, you want to go there.)

What about scientific content, you might ask? Jonathan Kolstad set the tone with an opening keynote lecture on the role of IT in physician response to pay for performance. The lecture combined theory with empirics, and I was rapidly drawn into a data-envy generating process. Tremendous physician and patient level data from the largest provider in Hawaii. Can you imagine the hardships of field work?

As for the presentations, we covered a broad range of topics. Luigi Siciliani, Helmuth Cremer and Francesca Barigozzi teamed up for a session on long-term care. Their theoretical approaches ranged from a standard IO two-sided market approach to strategic bequests and informal caregiving within the family. We had sessions on the regulation of drugs and unhealthy food, hospital, pharmaceutical and insurance markets, and on GP and health behavior. The paper by Marcos Vera-Hernandez (Identifying complementarities across tasks using two-part contracts. An application to family doctors) was a fantastic example of how to combine theory and empirical analysis. Johannes Schunemann gave a thought-provoking talk on The marriage gap: optimal aging and death in partnerships. I don’t quite agree with the assumptions and conclusions of the study, but then again I think that’s why I’m not a theorist… The main problem, in this case, is that there is nothing about the model that is specific to the variables being studied. We also covered the hot topic of antibiotic prescribing, with a model for prescription under uncertainty about resistance that got us all guesstimating our risk aversion.

The discussions within the workshop highlighted the potential benefits from having cross-field feedback. Empirically-minded researchers provided very useful feedback for theory articles, and vice-versa (for the few exceptions to the theory rule). In retrospect, I am convinced this arises from getting less caught up in technicalities of the theoretical model or the econometric specification, and placing a stronger emphasis on the basic assumptions of the models and the corresponding story.

All in all, we had a terrific time in Oslo. I was impressed by the level of collegiality amongst long-term participants, as well as their welcoming attitude towards newbies like myself. We worked hard and partied hard – even brought back dancing to EHEW – and I look forward to meeting up with the theorists in the near future. Lise, it’s on you!