Chris Sampson’s journal round-up for 25th March 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.

How prevalent are implausible EQ-5D-5L health states and how do they affect valuation? A study combining quantitative and qualitative evidence. Value in Health Published 15th March 2019

The EQ-5D-5L is able to describe a lot of different health states (3,125, to be precise), including some that don’t seem likely to ever be observed. For example, it’s difficult to conceive of somebody having extreme problems in pain/discomfort and anxiety/depression while also having no problems with usual activities. Valuation studies exclude these kinds of states because it’s thought that their inclusion could negatively affect the quality of the data. But there isn’t much evidence to help us understand how ‘implausibility’ might affect valuations, or which health states are seen as implausible.

This study is based on an EQ-5D-5L valuation exercise with 890 students in China. The valuation was conducted using the EQ VAS, rather than the standard EuroQol valuation protocol, with up to 197 states being valued by each student. Two weeks after conducting the valuation, participants were asked to indicate (yes or no) whether or not the states were implausible. After that, a small group were invited to participate in a focus group or interview.

No health state was unanimously identified as implausible. Only four states were unanimously rated as not being implausible. 910 of the 3,125 states defined by the EQ-5D-5L were rated implausible by at least half of the people who rated them. States more commonly rated as implausible were of moderate severity overall, but with divergent severities between states (i.e. 5s and 1s together). Overall, implausibility was associated with lower valuations.

Four broad themes arose from the qualitative work, namely i) reasons for implausibility, ii) difficulties in valuing implausible states, iii) strategies for valuing implausible states, and iv) values of implausible states. Some states were considered to have logical conflicts, with some dimensions being seen as mutually inclusive (e.g. walking around is a usual activity). The authors outline the themes and sub-themes, which are a valuable contribution to our understanding of what people think when they complete a valuation study.

This study makes plain the fact that there is a lot of heterogeneity in perceptions of implausibility. But the paper doesn’t fully address the issue of what plausibility actually means. The authors describe it as subjective. I’m not sure about that. For me, it’s an empirical question. If states are observed in practice, they are plausible. We need meaningful valuations of states that are observed, so perhaps the probability of a state being included in a valuation exercise should correspond to the probability of it being observed in reality. The difficulty of valuing a state may relate to plausibility – as this work shows – but that difficulty is a separate issue. Future research on implausible health states should be aligned with research on respondents’ experience of health states. Individuals’ judgments about the plausibility of health states (and the accuracy of those judgments) will depend on individuals’ experience.

An EU-wide approach to HTA: an irrelevant development or an opportunity not to be missed? The European Journal of Health Economics [PubMed] Published 14th March 2019

The use of health technology assessment is now widespread across the EU. The European Commission recently saw an opportunity to rationalise disparate processes and proposed new regulation for cooperation in HTA across EU countries. In particular, the proposal targets cooperation in the assessment of the relative effectiveness of pharmaceuticals and medical devices. A key purpose is to reduce duplication of efforts, but it should also make the basis for national decision-making more consistent.

The authors of this editorial argue that the regulation needs to provide more clarity, in the definition of clinical value, and of the quality of evidence that is acceptable, which vary across EU Member States. There is also a need for the EU to support early dialogue and scientific advice. There is also scope to support the generation and use of real-world evidence. The authors also argue that the challenges for medical device assessment are particularly difficult because many medical device companies cannot – or are not incentivised to – generate sufficient evidence for assessment.

As the final paragraph argues, EU cooperation in HTA isn’t likely to be associated with much in the way of savings. This is because appraisals will still need to be conducted in each country, as well as an assessment of country-specific epidemiology and other features of the population. The main value of cooperation could be in establishing a stronger position for the EU in negotiating in matters of drug design and evidence requirements. Not that we needed any more reasons to stop Brexit.

Patient-centered item selection for a new preference-based generic health status instrument: CS-Base. Value in Health Published 14th March 2019

I do not believe that we need a new generic measure of health. This paper was always going to have a hard time convincing me otherwise…

The premise for this work is that generic preference-based measures of health (such as the EQ-5D) were not developed with patients. True. So the authors set out to create one that is. A key feature of this study is the adoption of a framework that aligns with the multiattribute preference response model, whereby respondents rate their own health state relative to another. This is run through a mobile phone app.

The authors start by extracting candidate items from existing health frameworks and generic measures (which doesn’t seem to be a particularly patient-centred approach) and some domains were excluded for reasons that are not at all clear. 47 domains were included after overlapping candidates were removed. The 47 were classified as physical, mental, social, or ‘meta’. An online survey was conducted by a market research company. 2,256 ‘patients’ (people with diseases or serious complaints) were asked which 9 domains they thought were most important. Why 9? Because the authors figured it was the maximum that could fit on the screen of a mobile phone.

Of the candidate items, 5 were regularly selected in the survey: pain, personal relationships, fatigue, memory, and vision. Mobility and daily activities were also judged important enough to be included. Independence and self-esteem were added as paired domains and hearing was paired with the vision domain. The authors also added anxiety/depression as a pair of domains because they thought it was important. Thus, 12 items were included altogether, of which 6 were parts of pairs. Items were rephrased according to the researchers’ preferences. Each item was given 4 response levels.

It is true to say (as the authors do) that most generic preference-based measures (most notably the EQ-5D) were not developed with direct patient input. The argument goes that this somehow undermines the measure. But there are a) plenty of patient-centred measures for which preference-based values could be created and b) plenty of ways in which existing measures can be made patient-centred post hoc (n.b. our bolt-on study).

Setting aside my scepticism about the need for a new measure, I have a lot of problems with this study and with the resulting CS-Base instrument. The defining feature of its development seems to be arbitrariness. The underlying framework (as far as it is defined) does not seem well-grounded. The selection of items was largely driven by researchers. The wording was entirely driven by the researchers. The measure cannot justifiably be called ‘patient-centred’. It is researcher-centred, even if the researchers were able to refer to a survey of patients. And the whole thing has nothing whatsoever to do with preferences. The measure may prove fantastic at capturing health outcomes, but if it does it will be in spite of the methods used for its development, not because of them. Ironically, that would be a good advert for researcher-centred outcome development.

Proximity to death and health care expenditure increase revisited: a 15-year panel analysis of elderly persons. Health Economics Review [PubMed] [RePEc] Published 11th March 2019

It is widely acknowledged that – on average – people incur a large proportion of their lifetime health care costs in the last few years of their life. But there’s still a question mark over whether it is proximity to death that drives costs or age-related morbidity. The two have very different implications – we want people to be living for longer, but we probably don’t want them to be dying for longer. There’s growing evidence that proximity to death is very important, but it isn’t clear how important – if at all – ageing is. It’s important to understand this, particularly in predicting the impacts of demographic changes.

This study uses Swiss health insurance claims data for around 104,000 people over the age of 60 between 1996 and 2011. Two-part regression models were used to estimate health care expenditures conditional on them being greater than zero. The author analysed both birth cohorts and age classes to look at age-associated drivers of health care expenditure.

As expected, health care expenditures increased with age. The models imply that proximity-to-death has grown in importance over time. For the 1931-35 birth cohort, for example, the proportion of expenditures explained by proximity-to-death rose from 19% to 31%. Expenditures were partly explained by morbidity, and this effect appeared to be relatively constant over time. Thus, proximity to death is not the only determinant of rising expenditures (even if it is an important one). Looking at different age classes over time, there was no clear picture in the trajectory of health care expenditures. For the oldest age groups (76-85), health care expenditures were growing, but for some of the younger groups, costs appeared to be decreasing over time. This study paints a complex picture of health care expenditures, calling for complex policy responses. Part of this could be supporting people to commence palliative care earlier, but there is also a need for more efficient management of chronic illness over the long term.

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Chris Sampson’s journal round-up for 11th June 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.

End-of-life healthcare expenditure: testing economic explanations using a discrete choice experiment. Journal of Health Economics Published 7th June 2018

People incur a lot of health care costs at the end of life, despite the fact that – by definition – they aren’t going to get much value from it (so long as we’re using QALYs, anyway). In a 2007 paper, Gary Becker and colleagues put forward a theory for the high value of life and high expenditure on health care at the end of life. This article sets out to test a set of hypotheses derived from this theory, namely: i) higher willingness-to-pay (WTP) for health care with proximity to death, ii) higher WTP with greater chance of survival, iii) societal WTP exceeds individual WTP due to altruism, and iv) societal WTP may exceed individual WTP due to an aversion to restricting access to new end-of-life care. A further set of hypotheses relating to the ‘pain of risk-bearing’ is also tested. The authors conducted an online discrete choice experiment (DCE) with 1,529 Swiss residents, which asked respondents to suppose that they had terminal cancer and was designed to elicit WTP for a life-prolonging novel cancer drug. Attributes in the DCE included survival, quality of life, and ‘hope’ (chance of being cured). Individual WTP – using out-of-pocket costs – and societal WTP – based on social health insurance – were both estimated. The overall finding is that the hypotheses are on the whole true, at least in part. But the fact is that different people have different preferences – the authors note that “preferences with regard to end-of-life treatment are very heterogeneous”. The findings provide evidence to explain the prevailing high level of expenditure in end of life (cancer) care. But the questions remain of what we can or should do about it, if anything.

Valuation of preference-based measures: can existing preference data be used to generate better estimates? Health and Quality of Life Outcomes [PubMed] Published 5th June 2018

The EuroQol website lists EQ-5D-3L valuation studies for 27 countries. As the EQ-5D-5L comes into use, we’re going to see a lot of new valuation studies in the pipeline. But what if we could use data from one country’s valuation to inform another’s? The idea is that a valuation study in one country may be able to ‘borrow strength’ from another country’s valuation data. The author of this article has developed a Bayesian non-parametric model to achieve this and has previously applied it to UK and US EQ-5D valuations. But what about situations in which few data are available in the country of interest, and where the country’s cultural characteristics are substantially different. This study reports on an analysis to generate an SF-6D value set for Hong Kong, firstly using the Hong Kong values only, and secondly using the UK value set as a prior. As expected, the model which uses the UK data provided better predictions. And some of the differences in the valuation of health states are quite substantial (i.e. more than 0.1). Clearly, this could be a useful methodology, especially for small countries. But more research is needed into the implications of adopting the approach more widely.

Can a smoking ban save your heart? Health Economics [PubMed] Published 4th June 2018

Here we have another Swiss study, relating to the country’s public-place smoking bans. Exposure to tobacco smoke can have an acute and rapid impact on health to the extent that we would expect an immediate reduction in the risk of acute myocardial infarction (AMI) if a smoking ban reduces the number of people exposed. Studies have already looked at this effect, and found it to be large, but mostly with simple pre-/post- designs that don’t consider important confounding factors or prevailing trends. This study tests the hypothesis in a quasi-experimental setting, taking advantage of the fact that the 26 Swiss cantons implemented smoking bans at different times between 2007 and 2010. The authors analyse individual-level data from Swiss hospitals, estimating the impact of the smoking ban on AMI incidence, with area and time fixed effects, area-specific time trends, and unemployment. The findings show a large and robust effect of the smoking ban(s) for men, with a reduction in AMI incidence of about 11%. For women, the effect is weaker, with an average reduction of around 2%. The evidence also shows that men in low-education regions experienced the greatest benefit. What makes this an especially nice paper is that the authors bring in other data sources to help explain their findings. Panel survey data are used to demonstrate that non-smokers are likely to be the group benefitting most from smoking bans and that people working in public places and people with less education are most exposed to environmental tobacco smoke. These findings might not be generalisable to other settings. Other countries implemented more gradual policy changes and Switzerland had a particularly high baseline smoking rate. But the findings suggest that smoking bans are associated with population health benefits (and the associated cost savings) and could also help tackle health inequalities.

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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.

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