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

Using HTA and guideline development as a tool for research priority setting the NICE way: reducing research waste by identifying the right research to fund. BMJ Open [PubMed] Published 8th March 2018

As well as the cost-effectiveness of health care, economists are increasingly concerned with the cost-effectiveness of health research. This makes sense, given that both are usually publicly funded and so spending on one (in principle) limits spending on the other. NICE exists in part to prevent waste in the provision of health care – seeking to maximise benefit. In this paper, the authors (all current or ex-employees of NICE) consider the extent to which NICE processes are also be used to prevent waste in health research. The study focuses on the processes underlying NICE guideline development and HTA, and the work by NICE’s Science Policy and Research (SP&R) programme. Through systematic review and (sometimes) economic modelling, NICE guidelines identify research needs, and NICE works with the National Institute for Health Research to get their recommended research commissioned, with some research fast-tracked as ‘NICE Key Priorities’. Sometimes, it’s also necessary to prioritise research into methodological development, and NICE have conducted reviews to address this, with the Internal Research Advisory Group established to ensure that methodological research is commissioned. The paper also highlights the roles of other groups such as the Decision Support Unit, Technical Support Unit and External Assessment Centres. This paper is useful for two reasons. First, it gives a clear and concise explanation of NICE’s processes with respect to research prioritisation, and maps out the working groups involved. This will provide researchers with an understanding of how their work fits into this process. Second, the paper highlights NICE’s current research priorities and provides insight into how these develop. This could be helpful to researchers looking to develop new ideas and proposals that will align with NICE’s priorities.

The impact of the minimum wage on health. International Journal of Health Economics and Management [PubMed] Published 7th March 2018

The minimum wage is one of those policies that is so far-reaching, and with such ambiguous implications for different people, that research into its impact can deliver dramatically different conclusions. This study uses American data and takes advantage of the fact that different states have different minimum wage levels. The authors try to look at a broad range of mechanisms by which minimum wage can affect health. A major focus is on risky health behaviours. The study uses data from the Behavioral Risk Factor Surveillance System, which includes around 300,000 respondents per year across all states. Relevant variables from these data characterise smoking, drinking, and fruit and vegetable consumption, as well as obesity. There are also indicators of health care access and self-reported health. The authors cut their sample to include 21-64-year-olds with no more than a high school degree. Difference-in-differences are estimated by OLS according to individual states’ minimum wage changes. As is often the case for minimum wage studies, the authors find several non-significant effects: smoking and drinking don’t seem to be affected. Similarly, there isn’t much of an impact on health care access. There seems to be a small positive impact of minimum wage on the likelihood of being obese, but no impact on BMI. I’m not sure how to interpret that, but there is also evidence that a minimum wage increase leads to a reduction in fruit and vegetable consumption, which adds credence to the obesity finding. The results also demonstrate that a minimum wage increase can reduce the number of days that people report to be in poor health. But generally – on aggregate – there isn’t much going on at all. So the authors look at subgroups. Smoking is found to increase (and BMI decrease) with minimum wage for younger non-married white males. Obesity is more likely to be increased by minimum wage hikes for people who are white or married, and especially for those in older age groups. Women seem to benefit from fewer days with mental health problems. The main concerns identified in this paper are that minimum wage increases could increase smoking in young men and could reduce fruit and veg consumption. But I don’t think we should overstate it. There’s a lot going on in the data, and though the authors do a good job of trying to identify the effects, other explanations can’t be excluded. Minimum wage increases probably don’t have a major direct impact on health behaviours – positive or negative – but policymakers should take note of the potential value in providing public health interventions to those groups of people who are likely to be affected by the minimum wage.

Aligning policy objectives and payment design in palliative care. BMC Palliative Care [PubMed] Published 7th March 2018

Health care at the end of life – including palliative care – presents challenges in evaluation. The focus is on improving patients’ quality of life, but it’s also about satisfying preferences for processes of care, the experiences of carers, and providing a ‘good death’. And partly because these things can be difficult to measure, it can be difficult to design payment mechanisms to achieve desirable outcomes. Perhaps that’s why there is no current standard approach to funding for palliative care, with a lot of variation between countries, despite the common aspiration for universality. This paper tackles the question of payment design with a discussion of the literature. Traditionally, palliative care has been funded by block payments, per diems, or fee-for-service. The author starts with the acknowledgement that there are two challenges to ensuring value for money in palliative care: moral hazard and adverse selection. Providers may over-supply because of fee-for-service funding arrangements, or they may ‘cream-skim’ patients. Adverse selection may arise in an insurance-based system, with demand from high-risk people causing the market to fail. These problems could potentially be solved by capitation-based payments and risk adjustment. The market could also be warped by blunt eligibility restrictions and funding caps. Another difficulty is the challenge of achieving allocative efficiency between home-based and hospital-based services, made plain by the fact that, in many countries, a majority of people die in hospital despite a preference for dying at home. The author describes developments (particularly in Australia) in activity-based funding for palliative care. An interesting proposal – though not discussed in enough detail – is that payments could be made for each death (per mortems?). Capitation-based payment models are considered and the extent to which pay-for-performance could be incorporated is also discussed – the latter being potentially important in achieving those process outcomes that matter so much in palliative care. Yet another challenge is the question of when palliative care should come into play, because, in some cases, it’s a matter of sooner being better, because the provision of palliative care can give rise to less costly and more preferred treatment pathways. Thus, palliative care funding models will have implications for the funding of acute care. Throughout, the paper includes examples from different countries, along with a wealth of references to dig into. Helpfully, the author explicitly states in a table the models that different settings ought to adopt, given their prevailing model. As our population ages and the purse strings tighten, this is a discussion we can expect to be having more and more.



Alastair Canaway’s journal round-up for 29th January 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.

Is “end of life” a special case? Connecting Q with survey methods to measure societal support for views on the value of life-extending treatments. Health Economics [PubMed] Published 19th January 2018

Should end-of-life care be treated differently? A question often asked and previously discussed on this blog: findings to date are equivocal. This question is important given NICE’s End-of-Life Guidance for increased QALY thresholds for life-extending interventions, and additionally the Cancer Drugs Fund (CDF). This week’s round-up sees Helen Mason and colleagues attempt to inform the debate around societal support for views of end-of-life care, by trying to determine the degree of support for different views on the value of life-extending treatment. It’s always a treat to see papers grounded in qualitative research in the big health economics journals and this month saw the use of a particularly novel mixed methods approach adding a quantitative element to their previous qualitative findings. They combined the novel (but increasingly recognisable thanks to the Glasgow team) Q methodology with survey techniques to examine the relative strength of views on end-of-life care that they had formulated in a previous Q methodology study. Their previous research had found that there are three prevalent viewpoints on the value of life-extending treatment: 1. ‘a population perspective: value for money, no special cases’, 2. ‘life is precious: valuing life-extension and patient choice’, 3. ‘valuing wider benefits and opportunity cost: the quality of life and death’. This paper used a large Q-based survey design (n=4902) to identify societal support for the three different viewpoints. Viewpoints 1 and 2 were found to be dominant, whilst there was little support for viewpoint 3. The two supported viewpoints are not complimentary: they represent the ethical divide between the utilitarian with a fixed budget (view 1), and the perspective based on entitlement to healthcare (view 2: which implies an expanding healthcare budget in practice). I suspect most health economists will fall into camp number one. In terms of informing decision making, this is very helpful, yet unhelpful: there is no clear answer. It is, however, useful for decision makers in providing evidence to balance the oft-repeated ‘end of life is special’ argument based solely on conjecture, and not evidence (disclosure: I have almost certainly made this argument before). Neither of the dominant viewpoints supports NICE’s End of Life Guidance nor the CDF. Viewpoint 1 suggests end of life interventions should be treated the same as others, whilst viewpoint 2 suggests that treatments should be provided if the patient chooses them; it does not make end of life a special case as this viewpoint believes all treatments should be available if people wish to have them (and we should expand budgets accordingly). Should end of life care be treated differently? Well, it depends on who you ask.

A systematic review and meta-analysis of childhood health utilities. Medical Decision Making [PubMed] Published 7th October 2017

If you’re working on an economic evaluation of an intervention targeting children then you are going to be thankful for this paper. The purpose of the paper was to create a compendium of utility values for childhood conditions. A systematic review was conducted which identified a whopping 26,634 papers after deduplication – sincere sympathy to those who had to do the abstract screening. Following abstract screening, data were extracted for the remaining 272 papers. In total, 3,414 utility values were included when all subgroups were considered – this covered all ICD-10 chapters relevant to child health. When considering only the ‘main study’ samples, 1,191 utility values were recorded and these are helpfully separated by health condition, and methodological characteristics. In short, the authors have successfully built a vast catalogue of child utility values (and distributions) for use in future economic evaluations. They didn’t, however, stop there, they then built on the systematic review results by conducting a meta-analysis to i) estimate health utility decrements for each condition category compared to general population health, and ii) to examine how methodological factors impact child utility values. Interestingly for those conducting research in children, they found that parental proxy values were associated with an overestimation of values. There is a lot to unpack in this paper and a lot of appendices and supplementary materials are included (including the excel database for all 3,414 subsamples of health utilities). I’m sure this will be a valuable resource in future for health economic researchers working in the childhood context. As far as MSc dissertation projects go, this is a very impressive contribution.

Estimating a cost-effectiveness threshold for the Spanish NHS. Health Economics [PubMed] [RePEc] Published 28th December 2017

In the UK, the cost-per-QALY threshold is long-established, although whether it is the ‘correct’ value is fiercely debated. Likewise in Spain, there is a commonly cited threshold value of €30,000 per QALY with a dearth of empirical justification. This paper sought to identify a cost-per-QALY threshold for the Spanish National Health Service (SNHS) by estimating the marginal cost per QALY at which the SNHS currently operates on average. This was achieved by exploiting data on 17 regional health services between the years 2008-2012 when the health budget experienced considerable cuts due to the global economic crisis. This paper uses econometric models based on the provoking work by Claxton et al in the UK (see the full paper if you’re interested in the model specification) to achieve this. Variations between Spanish regions over time allowed the authors to estimate the impact of health spending on outcomes (measured as quality-adjusted life expectancy); this was then translated into a cost-per-QALY value for the SNHS. The headline figures derived from the analysis give a threshold between €22,000 and €25,000 per QALY. This is substantially below the commonly cited threshold of €30,000 per QALY. There are, however (as to be expected) various limitations acknowledged by the authors, which means we should not take this threshold as set in stone. However, unlike the status quo, there is empirical evidence backing this threshold and it should stimulate further research and discussion about whether such a change should be implemented.


Thesis Thursday: Koonal Shah

On the third Thursday of every month, we speak to a recent graduate about their thesis and their studies. This month’s guest is Dr Koonal Shah who has a PhD from the University of Sheffield. If you would like to suggest a candidate for an upcoming Thesis Thursday, get in touch.

Valuing health at the end of life
Aki Tsuchiya, Allan Wailoo
Repository link

What were the key questions you wanted to answer with your research?

My key research question was: Do members of the general public wish to place greater weight on a unit of health gain for end of life patients than on that for other types of patients? Or put more concisely: Is there evidence of public support for an end of life premium?

The research question was motivated by a policy introduced by NICE in 2009 [PDF], which effectively gives special weighting to health gains generated by life-extending end of life treatments. This represents an explicit departure from the Institute’s reference case position that all equal-sized health gains are of equal social value (the ‘a QALY is a QALY’ rule). NICE’s policy was justified in part by claims that it represented the preferences of society, but little evidence was available to either support or refute that premise. It was this gap in the evidence that inspired my research question.

I also sought to answer other questions, such as whether the focus on life extensions (rather than quality of life improvements) in NICE’s policy is consistent with public preferences, and whether people’s stated end of life-related preferences depend on the ways in which the preference elicitation tasks are designed, framed and presented.

Which methodologies did you use to elicit people’s preferences?

All four of my empirical studies used hypothetical choice exercises to elicit preferences from samples of the UK general public. NICE’s policy was used as the framework for the designs in each case. Three of the studies can be described as having used simple choice tasks, while one study specifically applied the discrete choice experiment methodology. The general approach was to ask survey respondents which of two hypothetical patients they thought should be treated, assuming that the health service had only enough funds to treat one of them.

In my final study, which focused on framing effects and study design considerations, I included attitudinal questions with Likert item responses alongside the hypothetical choice tasks. The rationale for including these questions was to examine the consistency of respondents’ views across two different approaches (spoiler: most people are not very consistent).

Your study included face-to-face interviews. Did these provide you with information that you weren’t able to obtain from a more general survey?

The surveys in my first two empirical studies were both administered via face-to-face interviews. In the first study, I conducted the interviews myself, while in the second study the interviews were subcontracted to a market research agency. I also conducted a small number of face-to-face interviews when pilot testing early versions of the surveys for my third and fourth studies. The piloting process was useful as it provided me with first-hand information about which aspects of the surveys did and did not work well when administered in practice. It also gave me a sense of how appropriate my questions were. The subject matter – prioritising between patients described as having terminal illnesses and poor prognoses – had the potential to be distressing for some people. My view was that I shouldn’t be including questions that I did not feel comfortable asking strangers in an interview setting.

The use of face-to-face interviews was particularly valuable in my first study as it allowed me to ask debrief questions designed to probe respondents and elicit qualitative information about the thinking behind their responses.

What factors influence people’s preferences for allocating health care resources at the end of life?

My research suggests that people’s preferences regarding the value of end of life treatments can depend on whether the treatment is life-extending or quality of life-improving. This is noteworthy because NICE’s end of life criteria accommodate life extensions but not quality of life improvements.

I also found that the amount of time that end of life patients have to ‘prepare for death’ was a consideration for a number of respondents. Some of my results suggest that observed preferences for prioritising the treatment of end of life patients may be driven by concern about how long the patients have known their prognosis rather than by concern about how long they have left to live, per se.

The wider literature suggests that the age of the end of life patients (which may act as a proxy for their role in their household or in society) may also matter. Some studies have reported evidence that respondents become less concerned about the number of remaining life years when the patients in question are relatively old. This is consistent with the ‘fair innings’ argument proposed by Alan Williams.

Given the findings of your study, are there any circumstances under which you would support an end of life premium?

My findings offer limited support for an end of life premium (though it should be noted that the wider literature is more equivocal). So it might be considered appropriate for NICE to abandon its end of life policy on the grounds that the population health losses that arise due to the policy are not justified by the evidence on societal preferences. However, there may be arguments for retaining some form of end of life weighting irrespective of societal preferences. For example, if the standard QALY approach systematically underestimates the benefits of end of life treatments, it may be appropriate to correct for this (though whether this is actually the case would itself need investigating).

Many studies reporting that people wish to prioritise the treatment of the severely ill have described severity in terms of quality of life rather than life expectancy. And some of my results suggest that support for an end of life premium would be stronger if it applied to quality of life-improving treatments. This suggests that weighting QALYs in accordance with continuous variables capturing quality of life as well as life expectancy may be more consistent with public preferences than the current practice of applying binary cut-offs based only on life expectancy information, and would address some of the criticisms of the arbitrariness of NICE’s policy.