Chris Sampson’s journal round-up for 3rd April 2017

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.

Return on investment of public health interventions: a systematic review. Journal of Epidemiology & Community Health [PubMed] Published 29th March 2017

Cost-effectiveness analysis in the context of public health is tricky. Often the health benefits are small at the individual level and the returns to investment might be cross-sectoral. Lots of smart people believe that spending on public health is low in proportion to other health spending. Here we have a systematic review of studies reporting cost-benefit ratios (CBR) or return on investment (ROI) estimates for public health interventions. The stated aim of the paper is to demonstrate the false economy associated with cuts to public health spending. 52 titles were included from a search that identified 2957. The inclusion and exclusion criteria are not very clear, with some studies rejected on the basis of ‘poor generalisability to the UK’. There’s a bit too much subjectivity sneaking around in the methods for my liking.  Results for CBR and ROI estimates are presented according to local or national level and grouped by ‘specialism’. From all studies, the median CBR was 8.3 and the median ROI was 14.3. As we might have suspected, public health interventions are cost-saving in a big way. National health protection and legislative interventions offered the greatest return on investment. While there is wide variation in the results, all specialism groupings showed a positive return on average. I don’t doubt the truth of the study’s message – that cuts to public health spending are foolish. But the review doesn’t really demonstrate what the authors want it to demonstrate. We don’t know what (if any) disinvestment is taking place with respect to the interventions identified in the review. The results presented in the study represent a useful reference point for discussion and further analysis, but they aren’t a sufficient basis for supporting general increases in public health spending. That said, the study adds to an already resounding call and may help bring more attention to the issue.

Acceptable health and priority weighting: discussing a reference-level approach using sufficientarian reasoning. Social Science & Medicine Published 27th March 2017

In some ways, the moral principle of sufficiency is very attractive. It acknowledges a desire for redistribution from the haves to the have-nots and may also make for a more manageable goal than all-out maximisation. It may also be particularly useful in specific situations, such as evaluating health care for the elderly, for whom ‘full health’ is never achievable and not a meaningful reference point. This paper presents a discussion of the normative issues at play, drawing insights from the distributive justice literature. We’re reminded of the fair innings argument as a familiar sufficientarian flavoured allocation principle. The sufficientarian approach is outlined in contrast to egalitarianism and prioritarianism. Strict sufficientarian value weighting is not a good idea. If we suppose a socially ‘acceptable’ health state value of 0.7, such an approach would – for example – value an improvement from 0.69 to 0.71 for one person as infinitely more valuable than an improvement from 0.2 to 0.6 for the whole population. The authors go on to outline some more relaxed sufficiency weightings, whereby improvements below the threshold are attributed a value greater than 0 (though still less than those achieving sufficiency). The sufficientarian approach alone is (forgive me) an insufficient framework for the allocation of health care resources and cannot represent the kind of societal preferences that have been observed in the literature. Thus, hybrids are proposed. In particular, a sufficientarian-prioritarian weighting function is presented and the authors suggest that this may be a useful basis for priority setting. One can imagine a very weak form of the sufficientarian approach that corresponds to a prioritarian weighting function that is (perhaps) concave below the threshold and convex above it. Still, we have the major problem of identifying a level of acceptable health that is not arbitrary. The real question you need to ask yourself is this: do you really want health economists to start arguing about another threshold?

Emotions and scope effects in the monetary valuation of health. The European Journal of Health Economics [PubMed] Published 24th March 2017

It seems obvious that emotions could affect the value people attach to goods and services, but little research has been conducted with respect to willingness to pay for health services. This study considers the relationship between a person’s self-reported fear of being operated on and their willingness to pay for risk-reducing drug-eluting stents. A sample of 1479 people in Spain made a series of choices between bare-metal stents at no cost and drug-eluting stents with some out-of-pocket cost, alongside a set of sociodemographic questions and a fear of surgery Likert scale. Each respondent provided 8 responses with 4 different risk reductions and 2 different willingness to pay ‘bids’. The authors outline what they call a ‘cognitive-emotional random utility model’ including an ’emotional shift effect’. Four different models are presented to demonstrate the predictive value of the emotion levels interacting with the risk reduction levels. The sample was split roughly in half according to whether people reported high emotion (8, 9 or 10 on the fear Likert) or low emotion (<8). People who reported more fear of being operated on were willing to pay more for risk reductions, which is the obvious result. More interesting is that the high emotion group exhibited a lower sensitivity to scope – that is, there wasn’t much difference in their valuation of the alternative magnitudes of risk reduction. This constitutes a problem for willingness to pay estimates in this group as it may prevent the elicitation of meaningful values, and it is perhaps another reason why we usually go for collective approaches to health state valuation. The authors conclude that emotional response is a bias that needs to be corrected. I don’t buy this interpretation and would tend to the view that the bias that needs correcting here is that of the economist. Emotions may be a justifiable reflection of personality traits that ought to determine preferences, at least at the individual level. But I do agree with the authors that this is an interesting field for further research if only to understand possible sources of heterogeneity in health state valuation.

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Chris Sampson’s journal round-up for 13th March 2017

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.

The effects of exercise and relaxation on health and wellbeing. Health Economics [PubMedPublished 9th Month 2017

Encouraging self-management of health sounds like a good idea, but the evidence is pretty weak. As economists, we know that something must be displaced in order to do it. This study considers the opportunity cost of time and how it might affect self-management activity and any associated benefits. Employment and education are likely to increase income and thus facilitate more expenditure on exercise. But the time cost of exercise is also likely to increase, meaning that the impact on demand is ambiguous. The study uses data from a trial of self-management support that included people with diabetes, COPD or IBS. EQ-5D, self-assessed health and the amount of time spent ‘being happy’ were all collected. Information was available for 12 different self-management activities, including ‘do exercises’ and ‘rest and relax’, and the extent to which individuals did these. Outcomes for 3,472 people at 12-month follow-up are estimated, controlling for outcomes at baseline and 6 months. The study assumes that employment and education affect health via their influence on exercise and relaxation. That seems a bit questionable and the other 10 self-management indicators could have been looked at to test this. People in full-time employment were 11 percentage points less likely to use relaxation to manage their condition, suggesting that the substitution effect on time dominates as the opportunity cost of self-management increases. Having a degree or professional qualification increased the probability of using exercise by 5 percentage points, suggesting that the income effect dominates. Those who are more likely to use either exercise or relaxation are also more likely to do the other. An interesting suggestion is that time preference might explain things here. Those with more education may prefer to exercise (as an investment) than to get the instant gratification of rest and relaxation. It’s important that policy recommendations take into consideration the fact that different groups will respond differently to incentives for self-management, at least partly due to their differing time constraints. The thing I find most interesting is the analysis of the different outcomes (something I’ve worked on). Exercise is found to improve self-assessed health, while relaxation increases happiness. Neither exercise or relaxation had a (statistically significant) effect on EQ-5D. Depending on your perspective, this either suggests that the EQ-5D is failing to identify important changes in broad health-related domains or it means that self-management does not achieve the goals (QALYs to the max) of the health service.

New findings from the time trade-off for income approach to elicit willingness to pay for a quality adjusted life year. The European Journal of Health Economics [PubMedPublished 8th March 2017

The question ‘what is a QALY worth’ could invoke any number of reactions in a health economist, from chin scratching to eye rolling. The perspective that we’re probably most familiar with in the UK is that the value of a QALY is the value of health foregone in order to achieve it (i.e. opportunity cost within the health care perspective). An alternative perspective is that the value of a QALY is the consumption value of health; how much consumption would individuals be willing to give up in order to obtain an additional QALY? This second perspective facilitates a broader societal perspective. It can tell us whether or not the budget is set at an appropriate level, while the health care perspective can only take the budget as given. This study relates mainly to decisions made with the ‘consumption value’ perspective. One approach that has been proposed is to assess willingness to pay for a QALY using a time trade-off exercise that incorporates trade-offs between length and quality of life and income. This study builds on the original work by using a multiplicative utility function to estimate willingness to pay and also bringing in prospect theory to allow for reference dependence and loss aversion. 550 participants were asked to choose between living 10 years in their current health state with their current salary or to live a reduced number of years in their current health state with a luxury income (pre-specified by the participant). Respondents were also asked to make a similar choice, but framed as a loss of income, between living 10 years at a subsistence income or fewer years with their current income. A quality of life trade-off exercise was also conducted, in which people traded reduced health and a lower income. The findings support the predictions of prospect theory. Loss aversion is found to be stronger for duration than for quality of life. Individuals were more willing to sacrifice life years to move from subsistence income to current income than to move from current income to luxury income. The results imply that quality of life and income are closer substitutes than longevity and income. That makes sense, given the all-or-nothing nature of being alive. Crucially, the findings highlight the need to better understand the shape of the underlying lifetime utility function. In all tasks, more than half of respondents were either non-traders or over-traded, indicating a negative willingness to pay. That should give pause for thought when it comes to any aggregation of the results. Willingness to pay studies often throw up more questions than answers. This one does so more than most, particularly about sources of bias in people’s responses. The authors identify plenty of opportunities for future research.

Beyond QALYs: multi-criteria based estimation of maximum willingness to pay for health technologies. The European Journal of Health Economics [PubMed] Published 3rd March 2017

Life is messy. Evaluating things in terms of a single outcome, whether that be QALYs, £££s or whatever, is necessarily simplifying and restrictive. That’s not necessarily a bad thing, but we’d do well to bear it in mind. In this paper, Erik Nord sets out a kind of cost value analysis that does away with QALYs (gasp!). The author starts by outlining some familiar criticisms of the QALY approach, such as its failure to consider the inherent value of life and people’s differing reference points. Generally, I see these as features rather than bugs, and it isn’t QALYs themselves in the crosshairs here so much as cost-per-QALY analysis. The proposed method flips current practice by putting societal preferences about fair and efficient resource allocation before attaching values to the outcomes. As such, it acknowledges the fact that society’s preferences for gains in quality of life differ from those for gains in length of life. For example, society may prefer treating the more severely ill (independent of age) but also exhibit a ‘fair innings’ preference that is related to age. Thus, quality and quantity of life are disaggregated and the QALY is no more. A set of tables is presented that can be read to assess ‘value’ in alternative scenarios, given the assumptions set out in the paper. There is merit in the approach and a lot that I like about the possibilities of its use. But for me, the whole thing was made less attractive by the way it is presented in the paper. The author touts willingness to pay – for quality of life gains and for longevity gains – as the basis for value. Anything that makes resource allocation more dependent on willingness to pay values for things without a price (health, life) is a big no-no for me. But the method doesn’t depend on that. Furthermore, as is so often the case, most of the criticisms within relate to ways of using QALYs, rather than the fundamental basis for their estimation. This only weakens the argument for an alternative. But I can think of plenty of problems with QALYs, some of which might be addressed by this alternative approach. It’s unfortunate that the paper doesn’t outline how these more fundamental problems might be addressed. There may come a day when we do away with QALYs, and we may end up doing something similar to what’s outlined here, but we need to think harder about how this alternative is really better.

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Chris Sampson’s journal round-up for 6th February 2017

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 review of NICE methods and processes across health technology assessment programmes: why the differences and what is the impact? Applied Health Economics and Health Policy [PubMed] Published 27th January 2017

Depending on the type of technology under consideration, NICE adopts a variety of different approaches in coming up with their recommendations. Different approaches might result in different decisions, which could undermine allocative efficiency. This study explores this possibility. Data were extracted from the manuals and websites for 5 programmes, under the themes of ‘remit and scope’, ‘process of assessment’, ‘methods of evaluation’ and ‘appraisal of evidence’. Semi-structured interviews were conducted with 5 people with expertise in each of the 5 programmes. Results are presented in a series of tables – one for each theme – outlining the essential characteristics of the 5 programmes. In their discussion, the authors then go on to consider how the identified differences might impact on efficiency from either a ‘utilitarian’ health-maximisation perspective or NICE’s egalitarian aim of ensuring adequate levels of health care. Not all programmes deliver recommendations with mandatory funding status, and it is only the ones that do that have a formal appeals process. Allowing for local rulings on funding could be good or bad news for efficiency, depending on the capacity of local decision makers to conduct economic evaluations (so that means probably bad news). At the same time, regional variation could undermine NICE’s fairness agenda. The evidence considered by the programmes varies, from a narrow focus on clinical and cost-effectiveness to the incorporation of budget impact and wider ethical and social values. Only some of the programmes have reference cases, and those that do are the ones that use cost-per-QALY analysis, which probably isn’t a coincidence. The fact that some programmes use outcomes other than QALYs obviously has the potential to undermine health-maximisation. Most differences or borne of practicality; there’s no point in insisting on a CUA if there is no evidence at all to support one – the appraisal would simply not happen. The very existence of alternative programmes indicates that NICE is not simply concerned with health-maximisation. Additional weight is given to rare conditions, for example. And NICE want to encourage research and innovation. So it’s no surprise that we need to take into account NICE’s egalitarian view to understand the type of efficiency for which it strives.

Economic evaluations alongside efficient study designs using large observational datasets: the PLEASANT trial case study. PharmacoEconomics [PubMed] Published 21st January 2017

One of the worst things about working on trial-based economic evaluations is going to lots of effort to collect lots of data, then finding that at the end of the day you don’t have much to show for it. Nowadays, the health service routinely collects many data for other purposes. There have been proposals to use these data – instead of prospectively collecting data – to conduct clinical trials. This study explores the potential for doing an economic evaluation alongside such a trial. The study uses CPRD data, including diagnostic, clinical and resource use information, for 8,608 trial participants. The intervention was the sending out of a letter in the hope of reducing unscheduled medical contacts due to asthma exacerbation in children starting a new school year. QALYs couldn’t be estimated using the CPRD data, so values were derived from the literature and estimated on the basis of exacerbations indicated by changes in prescriptions or hospitalisations. Note here the potentially artificial correlation between costs and outcomes that this creates, thus somewhat undermining the benefit of some good old bootstrapping. The results suggest the intervention is cost-saving with little impact on QALYs. Lots of sensitivity analyses are conducted, which are interesting in themselves and say something about the concerns around some of the structural assumptions. The authors outline the pros and cons of the approach. It’s an important discussion as it seems that studies like this are going to become increasingly common. Regarding data collection, there’s little doubt that this approach is more efficient, and it should be particularly valuable in the evaluation of public health and service delivery type interventions. The problem is that the study is not able to use individual-level cost and outcome data from the same people, which is what sets a trial-based economic evaluation apart from a model-based study. So for me, this isn’t really a trial-based economic evaluation. Indeed, the analysis incorporates a Markov-type model of exacerbations. It’s a different kind of beast, which incorporates aspects of modelling and aspects of trial-based analysis, along with some unique challenges of its own. There’s a lot more methodological work that needs to be done in this area, but this study demonstrates that it could be fruitful.

“Too much medicine”: insights and explanations from economic theory and research. Social Science & Medicine [PubMed] Published 18th January 2017

Overconsumption of health care represents an inefficient use of resources, and so we wouldn’t recommend it. But is that all we – as economists – have to say on the matter? This study sought to dig a little deeper. A literature search was conducted to establish a working definition of overconsumption. Related notions such as overdiagnosis, overtreatment, overuse, low-value care, overmedicalisation and even ‘pharmaceuticalisation’ all crop up. The authors introduce ‘need’ as a basis for understanding overconsumption; it represents health care that should never be considered as “needed”. A useful distinction is identified between misconsumption – where an individual’s own consumption is detrimental to their own well-being – and overconsumption, which can be understood as having a negative effect on social welfare. Note that in a collectively funded system the two concepts aren’t entirely distinguishable. Misconsumption becomes the focus of the paper, as avoiding harm to patients has been the subject of the “too much medicine” movement. I think this is a shame, and not really consistent with an economist’s usual perspective. The authors go on to discuss issues such as moral hazard, supplier-induced demand, provider payment mechanisms, ‘indication creep’, regret theory, and physicians’ positional consumption, and whether or not such phenomena might lead to individual welfare losses and thus be considered causes of misconsumption. The authors provide a neat diagram showing the various causes of misconsumption on a plane. One dimension represents the extent to which the cause is imperfect knowledge or imperfect agency, and the other the degree to which the cause is at the individual or market level. There’s a big gap in the top right, where market level causes meet imperfect knowledge. This area could have included patent systems, research fraud and dodgy Pharma practices. Or maybe just a portrait of Ben Goldacre for shorthand. There are some warnings about the (limited) extent to which market reforms might address misconsumption, and the proposed remedy for overconsumption is not really an economic one. Rather, a change in culture is prescribed. More research looking at existing treatments rather than technology adoption, and to investigate subgroup effects, is also recommended. The authors further suggest collaboration between health economists and ecological economists.

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